What important, immediate postoperative care practice should the nurse remember when caring for a woman who has had a mastectomy?
Venipuncture for blood work should be performed on the affected arm.
The blood pressure (BP) cuff should not be applied to the affected arm.
The affected arm should be held down close to the woman's side.
The affected arm should be used for intravenous (IV) therapy.
The affected arm should be used for intravenous (IV) therapy.
The Correct Answer is B
Choice A reason: This is incorrect because venipuncture for blood work should be avoided on the affected arm. The mastectomy may have involved the removal of lymph nodes, which can impair the lymphatic drainage and increase the risk of lymphedema (swelling) in the arm. Venipuncture can cause further damage or infection to the arm.
Choice B reason: This is correct because the BP cuff should not be applied to the affected arm. The BP cuff can exert pressure on the arm and interfere with the blood and lymph flow. This can also increase the risk of lymphedema or pain in the arm.
Choice C reason: This is incorrect because the affected arm should not be held down close to the woman's side. The woman should be encouraged to elevate the arm above the level of the heart and perform gentle exercises to promote circulation and prevent stiffness. The arm should not be immobilized or restricted.
Choice D reason: This is incorrect because the affected arm should not be used for IV therapy. IV therapy can introduce fluids or medications into the arm that can affect the blood and lymph flow. It can also cause irritation or infection to the arm.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: She will not be unable to conceive in the future, as ectopic pregnancy does not necessarily affect her fertility. However, she may have a higher risk of having another ectopic pregnancy or infertility if the fallopian tube is damaged or removed.
Choice B reason: A D&C (dilation and curettage) will not be performed to remove the products of conception, as this procedure is used to empty the uterus, not the fallopian tube. The treatment for ectopic pregnancy may include medication, surgery, or expectant management, depending on the location, size, and viability of the pregnancy.
Choice C reason: Bed rest and analgesics are not the recommended treatment for ectopic pregnancy, as they do not address the underlying cause or prevent complications. Ectopic pregnancy is a medical emergency that requires prompt intervention to prevent rupture, bleeding, and shock.
Choice D reason: Hemorrhage is the major concern for ectopic pregnancy, as the pregnancy can rupture the fallopian tube and cause severe bleeding into the abdominal cavity. This can lead to hypovolemic shock, which is a life-threatening condition.
Correct Answer is C
Explanation
Choice A reason: An FHR greater than 110 beats/min is not a sufficient indicator of fetal well-being during labor. The normal range of FHR is between 110 and 160 beats/min, but it can vary depending on the gestational age, fetal activity, and maternal factors. A high or low FHR may indicate fetal distress or compromise.
Choice B reason: Maternal pain control is not a direct measure of fetal well-being during labor. However, maternal pain can affect the FHR indirectly by causing maternal stress, anxiety, or hyperventilation, which can alter the blood flow and oxygen delivery to the fetus. Therefore, adequate pain management is important for both maternal and fetal health.
Choice C reason: The response of the FHR to UCs is the most reliable and accurate way of assessing fetal well-being during labor. UCs can cause temporary reductions in the blood flow and oxygen supply to the fetus, which can affect the FHR. A normal response of the FHR to UCs is either no change or a slight increase (acceleration), which indicates a well-oxygenated and resilient fetus. An abnormal response of the FHR to UCs is a decrease (deceleration), which indicates a compromised or hypoxic fetus.
Choice D reason: Accelerations in the FHR are not a definitive measure of fetal well-being during labor. Accelerations are transient increases in the FHR above the baseline, usually caused by fetal movement, stimulation, or UCs. Accelerations are generally reassuring and indicate a responsive and well-oxygenated fetus, but they are not always present or consistent. The absence of accelerations does not necessarily mean fetal distress, as some fetuses may have periods of sleep or reduced activity.
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